联合神经阻滞镇痛用于老年患者髋部骨折手术的效果

Efficacy of combined nerve block analgesia in elderly patients with hip fracture

目的探讨加速康复外科(ERAS)中优化老年髋部骨折患者围术期的镇痛方案。方法选择择期行髋部骨折手术的患者60例,年龄60~90岁,美国麻醉医师协会分级Ⅱ或Ⅲ级,随机分入联合神经阻滞镇痛组和对照组,每组30例。入院后两组均静脉注射NSAID,联合神经阻滞镇痛组同时行单次股神经阻滞,手术当日于蛛网膜下腔阻滞前30 min行连续髂筋膜间隙阻滞,术后持续镇痛。分别于入院后(T1)、术前做检查时(T2)、麻醉摆体位时(T3)、术后12 h(T4)、术后24 h(T5)和术后48 h(T6)各时间点进行静息和运动疼痛VAS评分,记录T1和T3时间点的患者平均动脉压(MAP)和心率,分别于术前和术后1 d测定CRP水平,记录补救镇痛情况、不良反应发生情况、住院时间和患者镇痛满意度。结果联合神经阻滞镇痛组T2至T5时间点的疼痛VAS评分均显著低于对照组同时间点(P值均<0.05),在T1、T6时间点,两组的疼痛VAS评分差异均无统计学意义(P值均>0.05)。联合神经阻滞镇痛组T3时间点的MAP显著低于对照组同时间点(P<0.05),T1时间点的MAP与对照组同时间点间的差异无统计学意义(P>0.05)。在T1、T3时间点,两组心率的差异均无统计学意义(P值均>0.05)。联合神经阻滞镇痛组术前、术后的血浆CRP水平分别为(39.07±32.55)、(63.74±29.91)mg/L,对照组分别为(26.50±21.79)、(69.16±39.92)mg/L,联合神经阻滞镇痛组患者术后血浆CRP水平显著低于对照组(P<0.05)。联合神经阻滞镇痛组术后发生不良反应5例(头痛1例、穿刺点疼痛1例、恶心呕吐3例),不良反应发生率为16.7%(5/30);对照组术后发生不良反应16例(头痛5例、恶心呕吐8例、谵妄3例),不良反应发生率为53.3%(16/30)。联合神经阻滞镇痛组术后不良反应发生率显著低于对照组(P<0.05)。联合神经阻滞镇痛组患者住院时间为(11.47±3.48)d,显著短于对照组的(15.10±5.72)d(P<0.05);镇痛满意度评分为(8.15±0.63)分,显著高于对照组的(6.52±0.51)分(P<0.05);补救镇痛率为3.3%(1/30),显著低于对照组的26.7%(8/30,P<0.05)。结论联合神经阻滞镇痛可安全、有效地应用于髋部骨折手术,不仅能提供良好的围术期镇痛,而且能减少应激和并发症发生,有利于老年髋部骨折患者加速康复。

Objective To optimize perioperative analgesia in elderly patients with hip fracture in enhanced recovery after surgery(ERAS).Methods Sixty patients with hip fracture,aged 60 to 90 years old,American Society of Anesthesiologists(ASA)physical statusⅡorⅢ,were randomly divided into combined nerve block analgesia group(n=30)and control group(n=30).After admission,non-steroidal anti-inflammatory drugs(NSAIDs)was injected intravenously in both groups,and single femoral nerve block was additionally performed in combined nerve block analgesia group.Continuous fascia iliaca compartment block was performed 30 min before spinal anesthesia in combined nerve block analgesia group.Visual analogue scale(VAS)scores at rest and during exercise were recorded after admission(T1),when preoperative examination began(T2),before anesthesia(T3),and 12 h(T4),24 h(T5)and 48 h(T6)postoperatively.The mean arterial pressure(MAP)and heart rate(HR)were recorded at T1 and T3.C-reactive protein(CRP)was measured before surgery and one day after surgery.Remedial analgesia,adverse reactions,length of stay and patients’satisfaction were also recorded.Results VAS scores from T2 to T5 in the combined nerve block analgesia group were significantly lower than those in the control group(all P<0.05),but no statistical difference was found in the VAS scores between the two groups at T1 or T6(both P>0.05).MAP at T3 in the combined nerve block analgesia group was significantly lower than that in the control group(P<0.05),while there was no significant difference in the MAP at T1 between group(P>0.05);neither was HR at T1 or T3(both P>0.05).Plasma CRP was(39.07±32.55)mg/L before surgery and(63.74±29.91)mg/L after surgery in the combined nerve block analgesia group,and were(26.50±21.79)mg/L and(69.16±39.92)mg/L in the control group,respectively.Postoperative plasma CRP level in the combined nerve block analgesia group was significantly lower than that in the control group(P<0.05).The incidence of adverse reactions was 16.7%(5/30)in the combined nerve block analgesia group,including 1 case of headache,1 case of puncture point pain,and 3 cases of nausea and vomiting.The incidence of adverse reactions was 53.3%(16/30)in the control group,including 5 cases of headache,8 cases of nausea and vomiting,and 3 cases of delirium.The incidence of adverse reactions in the combined nerve block analgesia group was significantly lower than that in the control group(P<0.05).Compared with those in the control group,the length of stay was significantly shortened([11.47±3.48]d vs.[15.10±5.72]d,P<0.05),analgesia satisfaction score was significantly increased(8.15±0.63 vs.6.52±0.51,P<0.05),and the rate of remedial analgesia was significantly decreased in the combined nerve block analgesia group(3.3%vs.26.7%,P<0.05).Conclusion Combined nerve block analgesia can be safely and effectively used in hip fracture surgery,which can not only provide good perioperative analgesia,but also reduce stress and complications,and accelerate the rehabilitation of elderly patients with hip fracture.